Chdd Abvrr & .Veq/ccr. Vol. IO. pp. 33-40. Pnnwd m the C S.A. All n&s rexr+xl
OIJS-:l34/86 5300 + 00 C 1986 Pcrgamon Prcu Ltd.
SYNDROME BY PROXY
JERRY G. JONES, M.D., HELEN L. BUTLER, M.D., BRENDA HA~~ILTON, R. N., JEANETTE D. PERDUE, M.S.W., A.C.S.W., H. PATRICK STERN, M.D., AND University
Sciences and Arkansas
Little Rock, AK
Abstract-!vlunchausen syndrome by proxy is a form of child abuse in which a disorder of the child is fabricated by a parent. Although often considered rare, it may have been overlooked frequently in the past. The reported cases of children with Munchausen syndrome by proxy range in age from infancy to 8 years. Their “illnesses” consist of fabricated histories. inflicted physical findings. altered laboratory specimens. and induced disorders. The perpetrator usually is the child’s mother. who may have Munchausen syndrome. Consequences of the syndrome may include painful tests, frequent hospitalizations. potentially harmful treatment. and death. The diagnosis can be made when medical and social histories are characteristic of the syndrome and clinical tindings are absent. suggestive of induced illness, or resolve upon separation of the child and parent. Suspicion of the syndrome should be discussed with the family once the safety of the child is insured, and the case should be reported under the child abuse reporting law of the state. Social, family, and medical histories must be obtained and verified, and court intervention should be considered. Four patients who illustrate typical features of the syndrome are described. Resume-Dans le syndrome de Munchausen par procuration. on se trouve en presence de s&ices h I’egard d’un enfant par le biais d’une maladie inventte par I’un des parents. On considtire souvenl que ce syndrome est grave mais en fait bien des cas ont 6chapp6 au diagnostic jusqu’a tout r&emment. L’Bge de I’enfant victime du syndrome de Munchausen par procuration va de la touts petite enfance jusque vers 8 ans. Les maladies de ces enfants consistent en anamneses falcif%es, en symtBmes physiques produits artificiellement, Cchantillons de laboratoire truquts et en desordres multiples produit volontairement. La fautive est la mire de I’enfant qui elle-mtme peut presenter le syndrome de Munchausen. Les conskquences du syndrome sent des examens douloureux, des hospitalisations rbp& (L-es, des traitements qui peuvent 6ventuellement faire du mal a I’enfant et cela peut aller jusqu’g la mart. On fait Ie diagnostic lorsque I’anamntise mbdicale et sociale suggerenl le syndrome et que les sympt6mes et signes cliniques ne sent pas compatibles avec I’anamn&e ou que les signes cliniques son1 suggestifs d’une maladie induite ou encore que ces signes cliniques disparaissent lorsqu’on separe le parent et I’enfant. Une fois que I’on est certain que I’enfant est en s0ett. les soupGons quant au syndrome devraient &Ire discutCs avec la famille et le cas devrair &re signal6 aux autoritCs de I’ttat en accord avec la loi sur le signalement des enfants maltraites. II faut naturellemenl obtenir une anamnese complete so&ale, familiale et medicale. cette anamnese doit Etre v5ritiee avec soin (la mire presenter un syndrome de Munchausen elle-m5me et d’autres enfants peuvent avoir eu des hospitalisations suspectes); ensuite Ie tribunal saisi de I’atTaire devrait intervenir. Les auteurs &riven1 quatre cas typiques pour illuslrer le syndrome de IMunchausen par procuration. I made a balloon of such extensive dimensions, that an account of the silk it contained would exceed all credibility. On the 30th of September, when the College of Physicians chose their annual officers, and dined sumptuously together. I filled my balloon. brought it over the dome of their building, clapped the sling round the golden ball at the lop, fastening the other end of it 10 the balloon. and immediately ascended with the whole college to an immense height, where I kept them upwards of three months. 11is a well known fact that during the three months the college was suspended in the air, and therefore incapable of attending their patients. no deaths happened, except a few. If the apothecaries had nor been very active during the above time, half the undertakers. in all probability. would have been bankrupt [I].
THIS IS A TYPICAL 18th century entertained Reprint
guests with apocryphal
tale of Baron Karl Fredrick Von Munchausen, who stories of his adventures. After a collection of his tales was
Jerry G. Jones, M.D.. Arkansas
804 Wolfe Street, Little Rock, AR 72202
J. G. Jones. H
L. Butler. B. Hdmllron.
J. D. Purdue. H
P Srern and R. C Wood\
published, he became famous throughout Europe. His fame as a storyteller was renewed 111 1951 ahen his name teas used to identify another type of storyteller . The term llunchsusen syndrome v.xs given to adults who produce false histories and fabricate physical signs and laboratory findings. causing themselves needless medical evaluations. operations and treatment. In 1977 Dr. Roy hleadow described in Lmwt a 6-hear-old girl who had recurrent blood! urine . She had repeated hospitalizations and tests all her life to find the cause. The urine findings bvere spurious. produced by the child’s mother. He gave the term “~lunchuusen svndrome by proxy” to describe this form of child abuse in ILhich a disorder of the child is fabricated by a paiient. Although often considered rare. this disorder may have been missed frequently 111the past due to failure of health professionals to consider it. The incidence may be increasing. because psychosocial disorders are afTected by changes in society and the structure of families. At Arkansas Children’s Hospital (ACH). NY have recently seen four patients ~ihn were diagnosed as having this interesting and important form of child abuse. Their case histories are provided. follokved by a discussion of the common features of the svndrome. diagn
CASE REPORTS Pnrienf f 1: A 23 month old was admitted
shaking spells, and periods of unresponsiveness Some episodes reportedly
with a history, from the mother. of apnea. perloral cyanosis.
required mouth to mouth resuscitation.
elsewhere and was maintained
at home on an apnea monitor.
mation from other sources relealed
apnea had been normal. During psychiatric evaluation She did not keep subsequent psychiatric
times during the 24 hours prior to admission. The patient had two previous hospitalizations
in the social history and that two previous workups of the mother, she admitted
the child’s history.
time constraints of a fictitious job. When legal
proceedings were begun to remove the child from the home. she robbed the person she was staying with and left the state. The social service agency in another
state was contacted,
and the child and mother were found with
relatives. The child was placed in foster care, and the mother committed Parlenr $2: diarrhea. patient
adopted child was admitted
The illness. which began with fever. scarlatina improved
in all parameters
herself to a psychiatric
IO another hospital because of prolonged vomiting and rash and headache, was treated with rrythromycin.
except for the vomiting
transfer to ACH.
was normal, as Uere routine chemistries and complete blood count. The patient had copious amounts
and large volume stools of up to 3 to 4 liters per day. Numerous
parasites were negative.
An upper GI
series, febrile a,,oolutinins
from the hospital,
of the abdomen
the presence of an antidepressant
blood and urine. The mother appeared caring; however. the diarrhea and the child was advanced
revealed several episodes of psychiatric
culture5 and e.\amination.\
and an ultrasound
care of the mother.
and an emetic in the
cleared within a few hours aft-zr removal of
to a regular diet within pseudoseizures
two days. Further
and previous nursing trnlning. Two
other adopted children had died at less than one year of age. and another adopted child had been removed from her custody; all three children ACH
to a court-ordered
had similar episodes of vomiting
The mother of a 7 year old reported by telephone
advised IO bring her child to ACH in the ambulance. appearance
and a normal
The patient was discharged from
outside the home. by ambulance.
that her child had 17 seizures that day. She v.35
On arrival, she claimed that her child had seven more seizure:, failed to confirm the mother
an alert and playful
history. the child had been born after a 6.5 months’ gestation, sat at 2 months. and began walking and speaking at 6 months. admission
Seizures began early in life, according
variety of anticon\ulsant
to the mother‘s
seizures. The child had received medvxl
history, the child was admitted
and this was the 38th hospital
care in four states. and treatment
While being observed almost constantly to complain
in adbersc side eft’ects. Because of the peculiar
that the child was having
for a week, the child had no uncontrollable
became furious with the nursing personnel when they failed to arrive in time to see them. Further
revealed that the mother’s three marriages were associated with frequent physical, mental and sexual abuse of the
htunchausen mother and her children.
syndrome by proxy
The responstble state agency obtained
a court order for foster care. and the child was
discharged to a foster home. The foster mother has reported no setzure acttvtty. Pulrenr =I:
A 3 year old was admitted to .ACH with a history. provided by the mother. of alternatmg
and stupor for the previous 3 days. The mother claimed that she had been child had been admitted
briefly to a community
appeared stuporous and intermittently erized tomography Aspirin.
delirious, and refleves were diffusely brtsk. lnittal studies included comput-
(CT). lumbar puncture, and toxicologic studies for a wide bartety of psychotropic
with the child continuously.
opiates. and barbiturates
were found tn the patient‘s blood. Although
and morphine had been used for sedation for the CT studtes. it was unclear who had given the chtld aspirin and diphenhydramine.
Over the next 24 hours the child began to regatn a normal mental status. Subsequent history
revealed that the mother had frequent hospital admissions and surpical procedures. including exploratory omy and cardiac hospitalization
and she had been identttied
as having hlunchausen
of the patient elsewhere was typical of Xlunchausen
diagnosis. The mother continued
syndrome by proxy. which was the discharge
that her child was having eptsodtc losses of consciousness and
delirium, although this was not confirmed in spite of careful observation by the medical stan‘. She deltghted in the performance
on her child. including
She usually stayed in or near the
hospital unit. but she frequently seemed more interested in the activities of the nurses than in mothering her child. The child was subsequently
placed in court-ordered
ation. Review of the records of two hospitalizations
foster care. The mother was to obtain a psychiatric
elsewhere of a siblin g revealed strong evidence of Munchau-
sen syndrome by proxy. and that child was also placed in foster care.
OF THE SYNDROME
The children of Munchausen syndrome by proxy range in age from infancy to 8 years. Little has been reported regarding their psychological states. Some of the older children appear to aid in their parents’ deceptions, perhaps to protect them [4-61. Their “Illnesses ”
Many parents of children with this disorder fabricate histories of illnesses. Reports of seizures are especially common; more than one-fourth of 76 cases mentioned by Meadows had false histories of seizures . Parents have supported their fabricated histories by creating spurious clinical findings, such as by putting blood of the perpetrator on or near the child to simulate hematemesis . Rashes have been simulated by rubbing or pricking the skin, applying caustics or painting with a dye [4, 81. The parents frequently produce false laboratory results. They have simulated hematuria, hematemesis, and hematochezia by contaminating their children’s laboratory specimens with blood obtained by pricking their own fingers, [3, 4, 91. They have added salt or fluids to blood specimens and altered thermometer readings . Parents also have induced illnesses. Children with Munchausen syndrome by proxy have been given poisons, which usually were medications readily available to the parents [3, 4, lo]. Diarrhea has been produced by excessive administration of laxatives; phenolphthalein (ExLax)B is the one most commonly used [ 1 I]. Parents have induced seizures by suffocation, carotid sinus pressure, and drugs . Polymicrobial bacteremia has been reported by injection of contaminated fluid into children’s intravenous tubing [ 12, 131. Cardiorespiratory arrest has been induced by suffocation [ 141. The Perpetrator
In essentially every reported case, the mothers of the children have been the perpetrators. Their fabrications typically are quite realistic, frequently reflecting prior nursing training. Approximately half of the mothers have been reported to have features of Munchausen syndrome, often having complaints similar to those attributed to their children .
Bu~irr. 83.Hamilton. _I. D. Perdue, H. P. Smn and R. C. u’~ood~,
When the children are hospitalized, their mothers usually appear especially attentive to them, frequently continuously remaining at their bedsides. The mothers tend to form close relationships vvith hospital personnel, often praisin g and reassuring them. Countertrsnsference feelings are frequently very strong amon “3 the staff, including the nurses. residents. medical students. social workers and child life specialists. Thus. commonly some of the personnel caring for the hospitalized child direct anger toward the one who First mentions the possibility of parental induced illness. Although occasional reports have described the psychopathology of the perpetrators. adequate studies of their psychological disorders are lacking. ?vte:adow reported that those referred to a psychiatrist “‘tended to emerge without a diagnostic label”’ 141.The aggressive acts may not be perceived as such by the abusive parents, who often see themselves as loving nnd caring . Although discussion with the parents of the suspicion of fabricated or induced illnesses is likely to result in denial, some parents admit their guilt with relief and accept psychiatric intervention. Others attempt suicide, become psychotic, or seek surgical procedures for themselves fs].
Little information regarding the fathers and siblings of children with Munchausen syndrome by proxy has been reported. The fathers. when in the home, generally are inconspicuous or weak, perhaps not closely involved with their children, and apparently unaware of the fabrications 14, 61. Some of the fathers appear to have the syndrome themselv”es. having illnesses observed only by their wives . Siblings of children with this disorder frequently are adversely affected. Seven siblings of 17 reported patients had either Munchausen syndrome by proxy, suffered nonaccidental injury, or died under suspicious circumstances [J].
CONSEQUENCES The physicai consequences of the unrecognized or inadequately managed syndrome include painful tests, long and frequent hospitalizations, and patentjally harmful treatment. For exampie, patient $2 described here had 16 days of hospitalization, 33 series of blood tests that involved at least 17 blood drawings, 8 urine tests, 9 stool tests and 4 radiologic series. Recently reported was a 2 year old who was taken to the operating room four times before a diagnosis of ~unchausen syndrome by proxy was made [ 151.Some children die as a result of induced illness. In a smail series of cases of this syndrome. the mortality was approximately 10% 141, The psychological consequences have not been adequately studied. Some of the children have Munchausen syndrome as adults .
DIAGNOSIS Munchausen syndrome by proxy should be considered in children under age 9 who have some of the signs listed in Table I. Once fabrication is suspected, the follovvin: steps to support the diagnosis are appropriate: 1. Separate the child from the mother to see if the symptoms or signs of iifness stilt occur, as wet1 as to protect the child. 2. Obtain a detailed social history, identifyin g typical symptomatology and dysfunctional dynamics within the family.
3. Obtain from the parents complete past medical histories of the child. parents and living or deceased siblings. and verify the histories by obtaining previous medical records. The latter can be difficult and time consuming. because medical care typically has been obtained from many sources in several localities. 4. Try to determine if past symptoms and signs of the child ha\-e occurred only kvhen the parent was present. Parents of children with this syndrome commonly report a third party witness . Such witnesses should be contacted for verification. 5. Collect specimens for toxicology studies on admission and nhen the symptoms or signs recur. 6. Repeat the evaluation and tests if induced physical findings or altered laboratory specimens are thought to be a possibility. The source of blood frequently can be determined bq comparing its type, Rh and other characteristics \vith that of the parent and child. 7. If the patient has diarrhea, consider the possibility of covert laxative administration. (Since phenolphthalein is the most likely laxative, alkalinize the stool to pH 8.5; its presence is indicated by development of a pink color. The stool that is pink initially and becomes clear with acidification also contains phenolphthalein.) Xlany laxatives can be identified by determination of stool levels of magnesium (normal < 98 mmol/l) and sulfate (normal < 4.5 mmol/l). Anthracene derivative laxatives lead to deposition of brown pigment in the colon, which can be seen by sigmoidoscopy. 8. Obtain a psychiatric evaluation of the parent, if possible. 9. Carefully document all findings in the medical record. The diagnosis is easily made when one has objective evidence such as identification of a poison in a child’s blood or urine, laboratory confirmation that blood in a child’s vomitus. urine, or stool is that of the parent, or observation of the parent in the act of inducing illness or contaminating a laboratory specimen. However, cases Lvill be missed if medical professionals rely on the presence of objective evidence. A diagnosis of Munchausen syndrome by proxy can be made when the medical and social histories are characteristic of the disorder and clinical findings are either absent or suggestive of induced illness.
MANAGEMENT The suspicion of fabricated or induced illness should be discussed frankly Lvith the parents once the safety of the child is insured. Sometimes, no further episodes of “illness” occur . The requirernent by law to report suspected child abuse to the specified state authorities. as
Signs of Munchausen
I. Persistent or recurrent illnesses for which a cause cannot be found between history and clinical findings 2. Discrepancies 3. Symptoms and signs that do not occur when a child is away from the mother Unusual symptoms, signs or hospital course that do not make clinical sense A differential diagnosis consisting of disorders less common than Munchausen syndrome by proxy
Persistent failure of a child 10 tolerate or respond 10 medical therapy without clear cause A parent less concerned than the physician. sometimes comforting the medical staff Repeated hospitalizations and vigorous medical evaluations of mother or child without detinitive diagnoses 9. A parent who is constantly at the child’s bedside. excessively praises the staff, becomes overly attached 10 the staff. or becomes highly involved in the care of other patients IO. A parent who welcomes medical Tess of her child. even when oainful
J. G. Jones. H. L. Budsr. B. Hmilron.
J. D. Prrdur, H. P.
Strrn and R.
the need to keep the chiid in the hospital pending the evaluation. should he clarified for the parents. Health professionals should align themselves with the caring part of the parents in explaining these actions, using phrases such as “my concern for the ;velEare of your child.” Emphasizing that the goal of social workers of the investigating state agency is “to assist families rather than prosecute them” enhances the likelihood of gaining parental cooperation during the evaluation. The child abuse statutes should be presented as beins enacted “to protect children who cannot defend themselves.” Concern for the mother should also be expressed and appropriate medical care secured for her. Presenting a suspicion of child abuse to a parent is al\vays ditficult, but especially so for professionals in a medical setting. The uncertainty of raisin g a suspicion that questions the integrity of a parent-child relationship generates strong emotions. Furthermore. these parents ostensibly are very caring people who present stories that generally are \‘ec credible. Ho\vever, medical professionals cannot avoid dealing with Munchausen syndrome b! proxy because of feelings of anxiety or guilt. They must intervene because of the potential morbidit! and mortality. as well as the legal requirement to report suspected child abuse. Social workers of the hospital and the investi~~~tin~ agency should attempt to verify the reported family and social histories, uhich often reveal inaccuracies . Hoivevrr. the physician should be responsible for obtaining the pertinent medical histories of family members. as even experienced social workers may have difficulty obtainin g the past medical histories of the child, siblings, and parents from the multiple sources of medical care. Since the time required can be considerable. the physician may need to share the resp~~nsibilit~ n-ith a social Lvorker or nurse. However, the roles of each professional should be clearly stated to insure that all relevant medical histories of the child and other family members are obtained. Most cases should be taken to juvenile court, although the need or type of legal intervention must be individualized for each family and locality. The court may order cooperation of the parent tvith the responsible social agency. psy~holo~i~~ll evalu~ltion of the parent, or removal of the child from the home. ‘4 court hearing frequently is necessary to gather all available information, including the medical records of family members. It also focuses the attention of nitnesses OII the case, resulting in medical and social information and rrcommendations that are clearer and more complete. In addition, compliance: of the parent in obtaining psy~holo~ic~~levaluation and in permitting social and psych~~l(~~i~~ll intervention is likeI> to be greater lvhen the management is court ordered. The difficult decision to request removal of a child from the home is ultimately made by the attorney of the responsible state agency, based largely on recommendations of medical and social work professionals. Unfortunately, the meager information available in published reports does not provide substantial guidance for predicting which children uould be safe, both physically and emotionally, if they are not removed. Meadow reported that nine children ivho remained in the home, with involvement of social services and continuing supsr\.ision, \vere knoivn to be tvell and free of all symptoms at follow-up one to four years later . T\vo children continued to be taken by their mothers to a variety of physicians because of apparently minor complaints. but neither “gross nor harmful” fabrication was taking place. Intuitively, one might suspect that children presentin, 0 with a fabricated history. manufactured clinical findings or altered laboratory specimens are in less physical danger than a child \vho has parental-induced disease; however, this speculation is unproven. Reported deaths of children with this syndrome obligate caution in predictin g the physical safety of those \+,ho remain in the home. Removal from the home when the diagnosis is made allows time for an experienced behavioral expert familiar with the syndrome to evaluate the parent’s psychopathology. ivillingness to establish a therapeutic relationship. and acceptance of the need to make personal changes. Additionally. it allows time for professionals to appraise the success of initial therapeutic
interventions. Evaluation of these factors likely will enable the behavioral expert. social workers and others to advise the court within a few weeks as to the physical safety of the child if returned to the home and the likelihood of successful management of the parent’s psychopathology if vigorous psychosocial support is provided. Whether the child remains in the home or returns to it from foster care. close medical. social and legal supervision must be provided. Hopefully. such support may lessen the possibility of future physical and emotional damage to the child or disclose evidence that will prompt reconsideration of request for court intervention. ‘Absence of fabricated or induced illnesses should not be the only measure of success in leaving a child in the home. Since unresolved psychopathology of the parent may atTect the child in other vvays. these children must be monitored for new physical and psychological manifestations. as vvell as recurrence of previous ones. The abusing parent must receive continuing psychiatric treatment. preferably ordered by the court. Since the short and long term emotional prognoses have not been established. formal psychological evaluation should be considered for children with hlunchausen syndrome by proxy. Criminal prosecution of the abusing parent can be considered. especially if the parent induced the child’s illness. However. some prosecutors may avoid difficult cases that have strong psychosocial components. Prosecution was not attempted in any of the four cases reported here.
CONCLUSION Professionals involved in the health care of children should be avvare of Jlunchausen syndrome by proxy. Although some cases may be self-evident. others require a high index of suspicion and clinical expertise. Failure to consider this diagnosis may result in unnecessary and potentially harmful tests and treatment, parent-intlicted injuries. or death. Health professionals are accustomed to believing parents. However. recognition of this important syndrome requires remembering that some parents. like Baron Von Munchuusen. fabricate stories. Their fabrications may be physically and emotionally tragic for their children.
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II. ROSEX. C. L.. FROST, J. D.. JR.. BRICKER. T.. TARNOW. J. D.. GILLETTE. P. C. snd DLNL.qvy. S. Two siblings wth rewrrrnt c~d~ompimtor) arrest: kfunchsusm sydroms by prox! or child ahuse? Pr&rr~ 71:715-720 (1953). 15. ~lAL;ZT.-\CK. 1. J., WIENER. E. S.. G.ARTNER, J. C., ZITELLI. B. J 2nd BRCXETTI. E. ‘rfunchauscn sydrome b\ prox): X new complication of central YCIIOUS catheterizatwn. Pc’d~~r~a X523-525 ( 1935).